Short-Stay Hospice Patients? Intractable?

Utilization of the Medicare hospice benefit by those dying continues to grow. In 2003, fewer than one out of every three Medicare decedents  received care from a  certified hospice. By 2007, that number had grown more than 30%, as 42% of decedents used  their hospice benefit during their final days (these figures are drawn from the Dartmouth Medical Atlas).

What hasn’t changed over that period are the number of short-stay (those who use the Medicare hospice benefit for a week or less) patients. One of out every three referrals to the hospice benefit.  So, late referrals continue to plague the hospice sector. Why? Theories abound, of course. You know them well, I’m sure.

And surely, it couldn’t be insufficient knowledge of hospice, as most hospices now deploy “community education” specialists to inform potential referring sources of their service offerings.  Prognostication tools have improved, so inability to confirm prognosis probably isn’t an explanation.

A growing number of HPM practitioners offer an intriguing theory.  It is, they say,  because the hospice benefit  does not “enable” concurrent care ,that is, curative treatment along with palliative measures. Patients, families, and physicians are hesitant to make early referrals to hospice  because the patient must choose to forego curative care.  Yet that does not lessen the need for, and the value of, palliative care. It simply means the providers of palliative care must be resourceful in marshaling the resources (reimbursement) to provide palliative care.   Palliative care, to be sure, may be provided under many health  plan benefits, including, of course,  the hospice benefit, the home health benefit, and Medicare Part B, for physician outpatient or home-based  visit coverage.

I'm curious to learn your experiences in this regard. Does this "concurrent care "disabling" theory hold true in your experience? 

Use of Hospice Benefit Grows, Late Referrals Persist

A recent discussion at a regional meeting of Hospice and Palliative Medicine practitioners grew lively when the subject turned to use of hospice, and whether use has grown. Following the meeting,  I reviewed NHPCO reports for 2010 and 2005. Turned out opposing viewpoints were each right, to some extent. Here's what I concluded.

• 30% growth in the percentage of Medicare decedents using hospice benefit. Impressive! 
• Short-stay patients (7 days or less) remained level at one-third of total deaths and discharges. Intractable?
• The size of hospices remained small - nearly 8 out of 10 have fewer than three admissions per week. Subscale?

Got me to thinking. If I was considering hospice care for a family member, aware that there is a one-in-three chance that the episode of hospice care will be no longer than a week, I'd want to select a hospice that admits twenty times the number of patients than the average-sized hospice. I figure that the additional volume would mean greater proficiency in short-stay care.
Does volume matter? No studies to prove either way. What do your professional instincts tell you?

Trends in Hospice and Palliative Medicine (HPM) Physician Compensation

Compensation for expertise does not always follow the supply/demand imbalance. Hospice and Palliative Medicine (HPM) physicians are a current example.

I’ve  been monitoring compensation practices for full-time HPM physicians for the past five years. Through  2010, I relied upon the Compensation Reports compiled by DAI Palliative Care Group (disclosure: I am employed by its parent company). I now rely upon the recently published report of HPM physician compensation and benefits, drawn from the findings of a survey by the American Academy of Hospice and Palliative Medicine (AAHPM) of its members. Nearly 800 AAHPM physician members responded to the survey conducted in November 2010, providing information regarding their 2009 compensation from practicing Hospice and Palliative Medicine (HPM).

As I review the reports over the preceding five years, several observations come to mind:

• Compensation for full-time HPM  physicians continues its rise, yet at a  slower pace than one would expect from a field marked by a shallow talent pool.
• The gap in compensation based upon place of employment is narrowing. Compensation for hospital based HPM physicians is somewhat greater than that for hospice-based physicians, but the difference is decreasing.
• Differences are insignificant for physicians practicing in urban, suburban, or rural areas. There are some regional differences, yet these too are insignificant. The greatest determinant of higher compensation is practicing HPM in a certificate-of-need state, such as Florida, where there is a concentration of larger-than-average size hospices who are more likely to deploy full-time physicians.
• Salary compression, unsurprisingly, is characteristic of the specialty. Average compensation for three position layers (team physician, associate medical director, and medical director) are little more than 10 percent.The best way to improve one’s compensation is to move into leadership positions, typically within hospices.
•  Compensation lags behind that of other specialties and primary care physicians (according to the 2010 AMGA Medical Group Compensation and Financial Survey the median salary for  is $214,000 for internists, $208,000 for family practitioners,  and $267,000 for emergency medicine physicians) .

The 2010 AAHPM report is chockful of information relative to compensation, benefits, and workload. I recommend its purchase (click here).

Reducing Hospital Readmissions: A Role for Hospice and Palliative Medicine Practitioners?

Hospices and their palliative medicine specialists have proven, several studies have shown, to be effective at reducing use of hospitals for their patients. In fact, families cite avoiding transitions among multiple settings as one of the benefits of hospice. In a previous post, we've examined the role of palliative medicine physicians in reducing readmissions.
One of the first financial impacts to hospitals resulting from PPACA legislation is a reduction in reimbursement for excessive readmission of Medicare inpatients. Starting with discharges in October 2011, the impact of the payment penalties may be significant.

The Medicare Payment Advisory Commission (MedPAC) has estimated that nearly one out of every five Medicare patients admitted to the hospital is readmitted within 30 days and unplanned readmissions are estimated to cost Medicare approximately $17.4 billion annually. Readmissions have become a widely accepted measure of hospital effectiveness. Although only one of many performance metrics, low readmission rates do correlate with overall clinical excellence.

As part of the CMS value-based purchasing program, 30-day readmission rates are a performance measure already closely watched in the industry. Now PPACA legislation allows CMS to withhold a portion of all inpatient Medicare payments due to excessive readmissions, starting with up to 1 percent in federal fiscal year 2013, and rising to 3 percent in 2015 and beyond.

Hospitals will likely look to post-acute care networks to assist in managing the care of at-risk (for rehospitalization) patients. Should we consider deployment of palliative care specialists (physicians and nurse practitioners) by these networks to visit patients in their homes (especially but not only when a referral has not been made to home health)? If not palliative care practitioners, then who?

Exemplar Hospitals for Late-Life Care

Geisinger Medical Center, in Danville, Pa., has become a favorite of President Obama when he discusses models of health care delivery worthy of emulation (so has Mayo Clinic and several others, but that's a subject for another post). It set me to wondering: how well does their (Geisinger) model translate into late-life care? Using data of palliative outcome measures drawn from the Dartmouth Medical Atlas, the research staff at DAI Palliative Care Group compiled a Hospital Palliative Performance Profile for Geisinger. Not unexpectedly, Geisinger produced a Palliative Performance Score of 105, earning it an A Grade and Exemplar Hospital status. Geisinger scored well in deaths by location (its patients were 8% less likely to die in the hospital than the national average) but where its performance stood out was in avoiding use of the ICU during a decedent’s last six months of life (Geisinger’s rate was less than half of the national average).

The DAI staff identified at least two other Exemplar Hospitals in Pennsylvania – Lancaster General Hospital (Lancaster) and Susquehanna Health System (Williamsport).
Susquehanna’s score dazzled us – 130, one of the highest in the nation. There are seven palliative outcome measures used to develop the Performance Profiles – Susquehanna scored better than the state and national averages in six of seven measures. For one measure, hospital days per decedent during the last six months of life, Susquehanna’s experience was nearly 40% better than the national rate. Surely, there must be lessons to be learned here, practices to be emulated.

Could it be that an Accountable Palliative Care Organization (APCO) has evolved over the past decade, under the leadership of a chief palliative care officer in the Williamsport community? Is there a “bellwether” HPM practice which contributes to the Hospital’s exemplar status? Suffice it to say, for the present, that there are exemplar hospitals and communities whose performance in late-life care suggests that there remains considerable room for improvement for most hospitals, and in most communities.

A Closer Look at an Exemplar Palliative Care Community - How Did They Do That?

Previous posts have taken a look at exemplar palliative care communities (read here , here , and here ) and the factors contributing to their exemplary performance. In this post, let's examine more closely another community (LaCrosse, Wisconsin) whose late-life care practices earned it exemplar status in the DAI Palliative Community Performance Profiles. The aim of our (DAI Palliative Care Group) studies of such communities (and their health care institutions) is to identify communities that have achieved results suggesting high performance in late-life care, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. These studies are intended to enable other hospice and palliative medicine (HPM) leadership to draw lessons from the experience of exemplar performers that will be helpful in their own efforts to become high performers. These communities, and health systems within the communities, we believe, are well-positioned to develop Accountable Palliative Care Organizations (APCOs).

In LaCrosse County, Gundersen Lutheran Health System has a market share of 59 percent of the inpatient cases. Gundersen is a physician-led, not-for-profit integrated delivery system serving an area with more than 550,000 people in a tristate region that includes parts of western Wisconsin, northeastern Iowa, and southeastern Minnesota. The population it serves, which is both urban and rural, is healthier, less transient, and more educated—but older and poorer—than the national median. The hub of the system is a 325-bed teaching hospital, which serves as the western clinical campus for the University of Wisconsin Medical School and the University of Wisconsin–Madison School of Nursing. While the hospital has an open medical staff, fewer than 5 percent of credentialed physicians are non–Gundersen Lutheran employees.

One of the keys to Gundersen Lutheran’s strategy for improving quality of care and lowering its cost is the optimal use of medical resources for patients with complex conditions and minimal social support. Through a care coordination program, the health system identifies patients who are frequently hospitalized—or who make frequent visits to the emergency care or urgent-care clinics, lack strong support at home, or simply have difficulty coping with the complexity of their health care needs—and assigns them to one of 28 registered nurses and social workers who are trained to help them navigate the health care system. The care coordination program has demonstrated significant cost savings. Charges per patient after 12 months in the program have fallen on average by $7,300 (generating net savings of $5,100 after accounting for program costs of $2,200 per patient), as patients are hospitalized less and make less frequent use of the emergency department for care. The hospital uses the program for its health plan members as well as for the fee-for-service population, though doing so reduces its hospital revenue. “This is living up to [the] mission of improving the health of the community,” says Jeffrey E. Thompson, M.D., Gundersen Lutheran’s CEO.

Lutheran has also increased coordination of care at the end of life—a time at which medical expenses rise—by implementing a comprehensive system for understanding, documenting, and honoring patient values and goals for care at the end of life in all health care settings. The documentation begins with the creation of advance directives that spell out what actions should be taken in the event that a patient is incapacitated or is no longer able to make decisions. Advance directives are embedded in the system’s electronic medical records and are made available to all providers in all care settings. Discussions are held and reviewed periodically during many types of patient encounters to make sure that plans remain current.

A strong partnership with other local providers and community groups promotes advance care planning among community members before they become terminally ill.
A training program developed in partnership with a competing local health system, Franciscan Skemp Healthcare (a division of Mayo Health System), and other community groups helps promote a consistent approach to advance care planning among social workers, chaplains, and other volunteers who carry out community education.

Partnership with other hospitals and community groups is essential to ensuring that conversations with patients about treatment preferences at the end of life—and the documentation of them—are consistent across settings and sites of care. Without such assurances, providers are tempted to dismiss documentation of treatment preferences from competitors because they are uncertain of the methods used to collect the information.

A recent study involving 400 deaths of residents of La Crosse County at all health care institutions over seven months in 2007 and 2008 found that 96 percent had either a written advance directive or a Physician Order for Life-Sustaining Treatment (POLST), a standardized medical order that reflects patient choices about key medical treatments often used at the end of life. An internal study among these patients found that those with advance directives used $2,000 less in physician and hospital services in the last six months of life.

In 2005, the health system began offering palliative care services to patients with end-stage disease, which reduced the rate of readmission by nearly two-thirds and lowered hospital-billed costs per patient by approximately $3,500 in the first 15 months of the program. Hospice and palliative providers have access to inpatient and outpatient medical records via the EHR, helping to ensure that patients who have serious and eventually fatal chronic conditions obtain seamless medical care across multiple settings, including home and hospital.

Owing in part to these programs, the cost of inpatient care at Gundersen Lutheran in the last two years of life was $18,359, or 29 percent lower than the national average of $25,860. The number of hospital days in the last two years of life was 13.5, nearly 43 percent lower than the national average of 23.6, according to data from the Dartmouth Atlas of Health Care on chronically ill Medicare beneficiaries.

For physicians who demonstrate leadership potential, the organization has created a physician learning community that helps them understand the strategic and business side of health care. The group meets monthly with the organization’s leaders to discuss institutional challenges and engage in problem-solving. The community also provides an opportunity to learn and practice leadership skills. Gundersen Lutheran does not use an incentive-based compensation system. Instead, salaries are set to be competitive in the market. Physicians are evaluated for productivity and citizenship; the latter is defined by adherence to a physician compact. They are also evaluated on measures of patient satisfaction, disease management, and patient access, which are recorded in the health system’s dashboard. The measurement feedback is critical to improvement.

To address this, Gundersen Lutheran uses data on clinical and financial outcomes to set goals for physicians to aspire to. Department chairs and administrators are also evaluated on such measures, which may include disease management targets and patient satisfaction measures, as well as measures of financial efficiency.

Gundersen has received national recognition and ratings, and The Commonwealth Fund Commission on a High Performance Health System identified Gundersen as a health sytem providing high-value care.

Several points come to mind. The power of partnerships and collaboration across the community. The influence of a palliative care network that spans acute, outpatient, and home settings. The importance of setting ambitious targets, and then monitoring and measuring performance. For LaCrosse, it took 15 years to become an overnight success. For most other communities, time is not on their side. HPM leaders would do well to accelerate their efforts to build attractive and influential palliative care "enterprises."